McKnight's Roundtable: Changes ahead

Accountable care organizations are dead in the water. Your facility could be cited for not providing wireless Internet for residents. The value of electronic medical records is still hypothetical.

These were a few of the bold statements and surprising facts to come out of a recent gathering of long-term care leaders in Chicago.

The McKnight's Roundtable Forum took place one day after the Health Insurance Portability and Accountability Act omnibus rule took effect, and 99 days before the Affordable Care Act's big Jan. 1 rollout. Participants jumped into a range of issues from technology to reimbursement to the ACA.

McKnight's Editorial Director John O'Connor and Editor James M. Berklan moderated the discussion. MDI Achieve sponsored the event, which was held at the Hyatt Regency in Chicago on Sept. 24.

The long-term care payment system was a frequently recurring topic. Participants criticized aspects of the current model that have already come under fire from many quarters, such as annual market basket cuts and a convoluted process of reviewing therapy claims.

“The payment systems are fundamentally flawed and misaligned in terms of incentives,” said Bill Altman, executive vice president of strategy and public policy for Kindred Healthcare.

Where's the gratitude?

Providers are penalized, or at least not rewarded, for the progress they are making in getting people home faster and reducing rehospitalizations, Altman noted. LTC providers also are not being rewarded for improving the risk adjustment factor and quality measures for managed care organizations.

Altman said the Centers for Medicare & Medicaid Services could exercise its regulatory authority to help providers move toward payment systems being tested through ACA demonstration projects, such as the accountable care organizations.

Golden Living President and CEO Neil Kurtz, M.D., begged to differ with ACO cheerleaders.

“I don't see any chance for ACOs to succeed in the current model,” he said.

The main issue, he explained, is that ACOs do not limit patients' choice of provider. This might make ACOs appealing from a consumer perspective, but it makes controlling cost and quality an impossible dream, he said.

The way ACO payments are managed also is a sticking point because healthcare providers such as hospitals act as the bundlers, and they have no experience in this area. Insurance companies do have this type of experience, and they recognize the necessity of limiting patient choice — witness the Affordable Care Act's health insurance marketplaces, which are excluding major medical centers in some states, Kurtz said. This aspect of the marketplaces, he anticipates, will lead to an “intense” outcry from libertarian-minded Republicans and the American people writ large, who have shown they do not like limited options when it comes to healthcare.

“I think we can all agree we will be more integrated, there will be different payment systems, but it's basically going to center around patient choice,” Kurtz said.

Market variations

No one objected to the idea that greater integration is inevitable, but there were differing takes.

Denise Wassenaar, chief clinical officer at MDI Achieve, said organizations such as ACOs are “here to stay,” but many are in their “infancy” and will continue to evolve.

Joyce Miller Evans, vice president and chief information officer at Ohio Presbyterian Retirement Services, used a metaphor evoking adolescence. She noted that hospitals have been forging partnerships for decades already. Now, even outside the formal ACO structure, many hospitals are trying to partner with good post-acute providers, she said.

“What hospitals did in the '90s and 2000s, that was like the prom, a lot of talk about who was taking whom to the dance,” she said. “Well, this is the after-prom, it's a lot more fun, a lot more going on in terms of choices.”

It may be impossible to gauge how developed integrated care networks are nationwide, due to notable variations among different markets, noted Kindred's Altman.

This point was driven home by Robert Siebel, president of Carriage Healthcare Companies, which primarily serves rural markets. He agreed that payment models are “definitely changing for good,” but said rural areas are not going to change as quickly — and this might be to their benefit.

Rural providers might learn from initiatives piloted in larger markets, but this does not mean they are sitting pretty. Siebel expressed great reservations about how post-acute providers would fare in a bundled payment system if the bundling were handled on the acute-care side.

The public utility model

While all the roundtable participants are grappling with “inevitable” ACA-related changes, they also are thinking creatively about alternative large-scale transformations of the sector. Some of the liveliest discussion concerned how well a public utilities model would work for long-term care.

Altman entertained the notion, saying it could be a “rational system” in which the government would guarantee rates of return necessary to attract capital and provide consistent services for the public good. It would be a way to avoid the reimbursement rate rebasing challenging the sector, he said.

Patricia Butler, vice president of strategic development at Advantage Management Group, cautioned that such a model might not incentivize innovation, and drew attention to the fact that electricity companies currently are going through deregulation — a process meant to encourage innovation and competitive rates for consumers.

Transforming long-term care to be reimbursed more like a public utility would not be a “utopia,” Kurtz conceded.

Laughing, he added, “But I'd kill for it.”

Tech citation disbelief

A number of roundtable participants bemoaned that long-term care so far has been shut out of government incentive funds to implement electronic medical records. But this issue was folded into a larger conversation about how technology is changing nearly every aspect of long-term care.

While many providers understandably are focused on implementing electronic medical records, it's essential to remember that facilities need to be equipped for the tech needs of residents as well as caregivers. One roundtable participant elicited gasps by sharing that surveyors recently tagged a facility for not providing wireless Internet access to its skilled nursing residents — even though the company does not advertise this service. The surveyors cited it as a quality of life issue. The provider might mount a challenge, so the ultimate outcome is still uncertain, but the larger point remains: Residents are increasingly tech-savvy, and the wave of baby boomers will come into facilities with high expectations in this area.

It's not all about technology such as Skype, noted Siebel, of Carriage Healthcare. “People's ability to self-monitor their health status will be huge,” he said.

The next generation of caregivers also will be more tech-centric. Many nursing school graduates are being trained exclusively on electronic systems and will enter the workforce without any experience in paper charting, according to Butler. This poses challenges for business continuity if a thin paper chart is the primary back-up. Providers may need to think hard about what kind of basic paper chart to keep in case of emergency and how to train recent graduates unfamiliar with paper charting systems.

Plus, LTC operators are behind the curve when it comes to digital file backups, said Susan Carman, vice president of information technology at Wingate Healthcare. She believes more companies are hiring security officers because the job has become so demanding and time-consuming. Compliance with the lengthy HIPAA omnibus rule, she noted, is daunting.

A call for simplification

The complexity of managing technology may be simply symptomatic of a larger change.

“We've made everything too complex,” said Jeff Bomberger, chief operating officer at Greystone Healthcare Management. “Every year, you want to do better, you add things, and you've got to measure and say, ‘Did we really do better?'”

Technology could help in measuring: MDI President and CEO John Damgaard stressed it arms LTC providers with needed data, especially when approaching potential network partners. But he was on the same page as Bomberger about overall simplification. He argued for a standardized business associate agreement. By having “the form” that everyone signs rather than subtly different forms, contract lawyers' fees could go toward improving care, he said.

EMRs: facts vs. feelings

Kindred's Altman noted a lack of data about EMR technology itself — and the data that has been published to date is somewhat inconclusive about quality gains specifically attributable to EMRs, or their cost effectiveness. Currently, LTC providers buying EMRs are investing in their “potential,” he said, adding “we all believe that EMRs will be a key enabler for management across an episode of care and to implement patient-centered care models.”

Brian Peters, chief information officer at CarDon & Associates, said he feels EMRs in fact have improved quality, with “feels” being the key word. Thanks to EMRs, he said, “Our nurses can go home feeling comfortable they've provided the best care they could. Can I put a number on it? No. But I can put a feeling around it.”

Altman agreed and said EMRs will prove themselves once providers rework care delivery processes to use them.

“We're definitely changing how we work,” said Aaron Durell, senior vice president and chief information officer at Altercare of Ohio. It's “not a short-term task” to integrate systems for maximum business intelligence, he noted.

Earlier in the day, Altman said that the ACA presents both “threats and opportunities.” Every industry constantly faces both, but long-term care and healthcare in general might be at a moment when it's hard to tell the two apart.

Roundtable participants highlighted that, in this era, operators more than ever are leveraging technology, engaging in creative problem-solving, and focusing steadfastly on care quality as they grapple with difficult decisions.